Taking the Pulse of Health Care and Politics

Politics and Medicine

"Medicine is, in many ways, very political," said Matthew Goldenberg, MD, associate professor of psychiatry at Yale School of Medicine in New Haven, Connecticut, whose research focuses on physician political beliefs and behaviors, "and there are many health-related topics that physicians may not think of as political or controversial that have been politicized in our culture."

These topics range far and wide – from universal health care to gun control, medical marijuana, physician-assisted suicide, "Right to Try" legislation, prescription drug costs, and even vaccinations.

The era of politicized health care seems to have shifted into high gear in 2010, when the ACA was enacted. Since then, health care delivery and national politics have become inseparable.

"Prior to the ACA, conventional politics related to health care were more budgetary in nature, dealing with Medicaid and Medicare coverage or fights over compensation for clinicians," said Thomas R. Oliver, PhD, professor of population health sciences at the University of Wisconsin School of Medicine and Public Health. "However, with the ACA, the fact that it was completely entangled in national politics at the highest level was inescapable. A decade later we still have conflict and disagreement over whether the ACA went too far or not far enough in addressing problems in our health care system."

The Personal and the Political

As medical professionals, physicians tend to not discuss their personal political views when taking care of patients, according to Dr. Goldenberg, but that doesn't mean that physicians are apolitical.

In 2016, Dr. Goldenberg and his colleague Eitan Hersh, PhD, associate professor of political science at Tufts University in Massachusetts, shared data about the political leanings of U.S. physicians by specialty with The New York Times.² Drs. Goldenberg and Hersh reviewed billing and specialty data from the federal government's National Provider Index, then matched more than 55,000 physicians in 29 states with available voter files that included party registration.

In their analysis, more than half of physicians with a recorded party affiliation were registered Democrats, but the percentages varied by specialty. For example, in psychiatry, infectious disease medicine, and pediatrics, more than two-thirds were registered Democrats. In surgery, anesthesiology, and urology, on the other hand, approximately two-thirds of physicians were registered Republicans. Oncologists fell somewhere in the middle: 43% were registered Republicans.

"What we don't know is when those political beliefs developed," Dr. Goldenberg told ASH Clinical News. "Did people who were more Democratic-leaning go into certain specialties, or did their political beliefs develop later? My guess is that it is a combination."

Regardless of individual political leanings, most physicians agree that the exam room should be off limits from political discussions.

"Politics, Democrats, Republicans, who you are voting [for] … none of that belongs in the exam room," said Joshua M. Sharfstein, MD, from Johns Hopkins Bloomberg School of Public Health in Baltimore. "Doctors provide care to patients, regardless of either side's political beliefs."

Jason Westin, MD, a lymphoma specialist from the University of Texas MD Anderson Cancer Center, said that he has noticed that patients are increasingly aware of the relationship between health care and politics, but, in response, physicians typically try to steer clear of these topics and focus instead on science and medicine.

"During the 2016 campaign, patients should have gotten the same care whether they were wearing a Hillary Clinton button or a MAGA hat," Dr. Westin said. "If a patient brings up politics, most doctors will deflect or make a generic comment and then move on to the medical issues at hand."

Dr. Westin knows firsthand about walking the tightrope between being politically active in his personal life and politically neutral in his work life: In 2017, he ran for a U.S. Congressional seat in his home state of Texas. His campaign ended when he lost the Democratic primary, but when ASH Clinical News spoke with him that year about whether patients were aware of his political ambitions, he noted, "I'm not hiding the fact that I'm running for Congress, but I'm also not bringing it up with patients in the clinic. I don't want politics to have any impact on the care that I'm delivering to my patients."

He also waved off fears about potential conflicts with patients: "I haven't yet had any patients leave the clinic or change doctors, and I think that's because of the personal relationships we've formed. We may disagree on a specific policy, but … my patients recognize that there is more to me than my political beliefs. … They're mostly worried about whether I'll be able to keep taking care of them if I win."

"Politics, Democrats, Republicans, who you are voting [for] … none of that belongs in the exam room. Doctors provide care to patients, regardless of either side's political beliefs."

—Joshua M. Sharfstein, MD

Hot Button Issues

Despite efforts to check politics at the clinic door, political beliefs may unconsciously shape treatment decisions or discussions that physicians have with patients, according to research from Drs. Hersh and Goldenberg. In 2016, they published a study examining whether primary care physicians changed how they handle various health issues based on party affiliation.³

Participants were asked to respond to a series of vignettes that addressed many politicized health issues – including medical marijuana, abortion, and firearm storage – then to rate the seriousness of the issue presented and their likelihood of engaging in specific management options.

"On the politicized health issues … Democratic and Republican physicians differed substantially in their expressed concern and their recommended treatment plan," the authors wrote. For example, Democratic physicians considered the vignettes related to firearms to be more concerning, while Republican physicians rated the marijuana and abortion vignettes as more worrisome.

"This shows that at the doctor-patient level, the political views of a physician can, at times, impact the care that is delivered," Dr. Goldenberg said.

While several health care–related topics have become polarizing, Dr. Sharfstein believes that there also may be an emerging number of issues where Republicans and Democrats are finding common ground. Researchers at Johns Hopkins reviewed county-level health outcomes data to try to predict whether counties would vote Democratic or Republican in the 2016 Presidential election but found that there was substantial overlap between red and blue counties.⁴

From these data, they also found a "bipartisan health agenda," wherein both parties agreed on the significance of the following topics: providing health insurance for people with pre-existing conditions, expanding Medicaid to low-income populations, enacting legislation to address the opioid epidemic, instituting payment reform, and – perhaps the issue with the most widespread support – lowering drug prices.

The high costs of health care and prescription drugs are a top priority for politicians, physicians, and patients. More than half of Americans said that paying for health services affected their household's financial situation "a lot," according to a 2018 Pew Research poll.⁵ And, given the estimates that the mean costs of anticancer drugs increased fivefold from 2006 to 2015, the issue's importance will not fade any time soon.⁶

Drug pricing is on the mind of politicians and constituents, and it's an issue that frequently comes up between physicians and patients in the exam room, according to Dr. Westin.

"Many physicians are bothered by the cost of prescription drugs and may discuss differently priced options for patients," Dr. Westin said. "In some cases, I could see those conversations going further than that initial drug pricing discussion to other politically charged issues."

The widespread agreement on this issue may be why several prominent hematologists and oncologists have joined the crusade against high drug prices. Vincent Rajkumar, MD, of the Mayo Clinic in Rochester, Minnesota, and Hagop Kantarjian, MD, of MD Anderson Cancer Center, are outspoken advocates of lowering drug prices, stating that "oncologists have a moral obligation to advocate for affordable cancer drugs."⁷

"Drug prices are a real problem because a lot of the medications hematologists and oncologists use in day-to-day practice are very powerful, on-patent chemotherapy and immunotherapy agents that can be incredibly expensive," Dr. Westin said. "This creates a real barrier to translating science into patient benefit."

The problem is only going to worsen as more revolutionary, one-time gene therapies enter the treatment landscape.

For example, Dr. Westin said, "Chimeric antigen receptor (CAR) T-cell therapy is an incredible advance for patients with relapsed leukemia or lymphomas, but it is still available to only a small number of patients. As availability grows, it is going to increase stress on our system, and decisions may have to be made about whether all patients who qualify get it, or if pricing will create barriers to care." (Editor's note: On August 2, 2019, the Centers for Medicare and Medicaid Services issued a final rule that raises payments for new technologies, including CAR T-cell therapies, from 50 percent to 65 percent. Although medical organizations welcomed the increase, some argued that the increase may not provide enough relief for hospitals and patients.)

The Ethics of It All

Mixing politics and patients is a complicated issue, and one without well-defined standards of practice.

The American Medical Association addresses "political communications" in its Code of Medical Ethics and, although the code does not strictly prohibit the discussion of political views, it suggests that physicians "refrain from initiating political conversations during the clinical encounter" and that "physicians must not allow differences with the patient or family about political matter to interfere with the delivery of professional care."⁸

"Physicians who are taking care of patients have a fiduciary responsibility to the patient, and we don't want to do anything that would unnecessarily interfere with the doctor-patient relationship," Dr. Goldenberg said. "I would not want to alienate my patients by talking about politics in a way that might make them less likely to come see me or to follow my medical recommendations."

According to Dr. Westin, if a physician started expressing strong political views during patient encounters, the patient would likely complain.

"Doctors are human beings and unconscious biases are hard to control, but most physicians model their behavior after the physicians who trained them," Dr. Westin said. "That model is often a calm physician who does not get too excited or too down based on any scenario, and that includes politics."

As health care becomes more politicized, perhaps medical training needs to start addressing political bias, Dr. Goldenberg suggested. "Political biases and awareness of one's own biases should be incorporated into our training, just as other biases are," he said.

Dr. Oliver added that training on political bias is just one piece of promoting "cultural humility" in medical education. "The idea of cultural humility is that we don't ever know what is going on inside someone else's mind until they volunteer the information, or we gently coax it out," he explained.

"Instead of avoiding the topic of politics and political bias, we need to train physicians on how to handle these situations if they come up at the bedside or in the exam room," Dr. Oliver said.

Don't Ask, Don't Counsel

Even as physicians attempt to remain apolitical in the exam room, politics occasionally have been inserted into the doctor-patient relationship by governing entities. One famous example is Florida's Firearm Owners' Privacy Act – considered by many to be "a physician gag law" – that attempted to prohibit physicians from asking patients about whether they owned a gun and counseling them on gun safety. The law was later struck down as a violation of physicians' First Amendment rights.

Other state-enacted legislation requires doctors to provide patients with certain information prior to performing or making a referral for an abortion, despite the physician's professional opinion on the topic.

Such legislation has been met with criticism from medical societies. For example, in 2013, the American College of Obstetricians and Gynecologists released a statement that "laws that require physicians to give, or withhold, specific information when counseling patients, or that mandate which tests, procedures, treatment alternatives or medicines physicians can perform, prescribe, or administer are ill-advised."⁹ These laws prevent physicians from offering the best evidence-based care, they continued: "Medical knowledge is not static. As knowledge advances, these protocols, tests, and procedures will become outdated. Legislation should not override scientific progress."

Time to Speak Up

Political engagement is another route for physicians to care for patients, according to the AMA's Code of Medical Ethics, which recommends clinicians "work toward and advocate for the reform and proper administration of laws related to health care [and] stay well informed about needed or proposed policies concerning health care access and quality, medical research, and promoting public health."

Whether physicians express their political opinions as health care professionals, they do have an important role in the political process as individuals, Dr. Westin noted.

"Physicians, being largely apolitical in day-to-day practice, many times misunderstand their importance in society when it comes to politics and policy," he said. "The general public gives us a respect and authority that is largely well-deserved based on expertise in medicine, but by remaining silent in advocacy, we allow others to speak for us – or to speak louder than us – and, therefore, abdicate responsibility to help patients in other ways besides the delivery of health care."

That motivation fueled Dr. Westin's campaign in 2017, which he launched with the help of a proscience advocacy group called 314 Action. The group is committed to electing scientists and STEM professionals to public office. Although his campaign was unsuccessful, Dr. Westin still believes physicians should step up and use their voices.

Dr. Goldenberg echoed this sentiment. The clinical care a person receives accounts for only a portion of health outcomes; the social determinants of health – income, education, employment, community safety, discrimination including racism, and family/social support – play a large role in patients' outcomes.¹⁰

"Regardless of medical specialty, physicians should use our power to raise awareness about the importance of social determinants of health," Dr. Goldenberg urged. "By not doing so, we are not addressing major issues that ultimately impact health."

Despite the importance of political involvement, many physicians are not particularly politically active, either from a lack of interest or a lack of time. Others may not want to politicize the field of medicine any more than it already is.

For busy physicians, the best way to advocate is often through the medical societies and organizations they support. The American Society of Hematology provides up-to-date information on its advocacy efforts (hematology.org/Advocacy) and asks for participation from its members in support of a wide variety of issues affecting hematology research and practice and patient access to care, including items such as the Cancer Drug Coverage Parity Act, National Institutes of Health funding, and funding for sickle cell disease data collection.

"More hematologists and oncologists, and physicians in general, need to be engaged in the political process, whether it is running for office or testifying or supporting groups that shape policy," Dr. Westin said. "If we don't, someone else will do it for us.” —By Leah Lawrence